Learner Pre-Assessment Questionnaire

Personal Details

Title

For example, Miss, Mr, Mx, Dr.

Name

First

Last

Address

Type a POSTCODE and select the correct address from the options. Add a HOUSE number in the next box.

House number or name

Enter the HOUSE number or name here.

Email Address

Phone Number

Date of Birth

Medical Conditions

What is your medical condition?

How does it affect you?

Describe your physical ability.

Do you use any walking aids or a wheelchair?

If you answered "Yes" please tell us what you use.

Have you ever had seizures or fits?

If you’ve been given medicines by a doctor, please list them here:

Have you been diagnosed with Epilepsy?

Your Doctor

What is your doctor's name?

Address of your doctor's practice

Please provide the full address including the postcode.

Doctor's phone number

Eyesight

Do you need glasses or contact lenses for driving?

Can you read a number plate at 20 metres away with or without glasses?

If you answered "No", please contact Herts Ability as soon as possible by calling 01707 324581

Have you ever been diagnosed with a visual field defect?

If you answered "Yes", please include it here

About you

How comfortable do you feel about meeting new people?

Very comfortable
Somewhat comfortable
Not very comfortable
Not at all comfortable

How comfortable do you feel about being in a new place?

Very comfortable
Somewhat comfortable
Not very comfortable
Not at all comfortable

Educational Support

How are your reading skills?

Excellent
Average
Poor

How are your writing skills?

Excellent
Average
Poor

How are your computer skills with regards to using a keyboard and mouse?

Excellent
Average
Poor

How is your concentration?

Excellent
Average
Poor

How comfortable do you feel when taking exams?

Very comfortable
Somewhat comfortable
Not very comfortable
Not at all comfortable

Answer to extra support received in education

Theory Test Information

Have you passed your Theory Test?

How many Theory Tests have you attempted?

What do you think caused you to have difficulty when attempting the Theory Test?

For example, "difficulty concentrating".

What revision have you done so far?

Mark all that apply.

Do you have any of the following?

Mobile phone
Tablet or iPad
Laptop or desktop computer

Mark all that apply.

Driving Tuition

How many hours of driving tuition have you taken so far?

None
1 to 4 hours
5 to 10 hours
More than 10 hours

If you’ve taken tuition, what sort of car did you use?

Manual transmission
Automatic transmission

If you’ve taken any tuition, what did you find difficult?

Please type your answer.

What type of car would you like to use for your assessment?

Manual
Automatic

Do you have any concerns about driving?

Your Driving Licence

What is your Provisional Driving Licence number?

Example Provisional Driving Licence with the licence number highlighted: Example Driving Licence showing the Driver Number

What is your National Insurance (NI) number?

It’s on your National Insurance card, benefit letter, payslip or P60. For example, ‘AB 12 34 56 C’.

Example National Insurance card:

We need this to check your licence online. Once we’ve checked, your number will be removed from our system.

Declaration

number name practice

Did you complete this for yourself?

If someone completed this form for you, please provide their full name here

Herts Ability

Suite 4, Wentworth Lodge
Great North Road
Welwyn Garden City
Hertfordshire
AL8 7SR

Registered charity No. 1059015